ARCHETYPE Fundoscopic examination of eyes (openEHR-EHR-OBSERVATION.fundoscopic_examination.v0)

Name: Fundoscopic examination of eyes
License: http://creativecommons.org/licenses/by-sa/3.0/

ARCHETYPE ID	openEHR-EHR-OBSERVATION.fundoscopic_examination.v0
Concept	Fundoscopic examination of eyes
Description	Record of clinical findings on fundoscopy of eyes.
Purpose	To record details about clinical findings on fundoscopy of eyes.
References	Lamirel C, Bruce BB, Wright DW, Delaney KP, Newman NJ, Biousse V. Quality of nonmydriatic digital fundus photography obtained by nurse practitioners in the emergency department: the FOTO-ED study. Ophthalmology. 2012 Mar;119(3):617-24. doi: 10.1016/j.ophtha.2011.09.013. Epub 2012 Jan 3. PubMed PMID: 22218140; PubMed Central PMCID: PMC3294008. Grading diabetic retinopathy from stereoscopic color fundus photographs--an extension of the modified Airlie House classification. ETDRS report number 10. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. 1991 May;98(5 Suppl):786-806. PubMed PMID: 2062513. Li HK, Horton M, Bursell SE, Cavallerano J, Zimmer-Galler I, Tennant M, Abramoff M, Chaum E, Debuc DC, Leonard-Martin T, Winchester M; American Telemedicine Association Diabetic Retinopathy Telehealth Practice Recommendations Working Group., Lawrence MG, Bauman W, Gardner WK, Hildebran L, Federman J. Telehealth practice recommendations for diabetic retinopathy, second edition. Telemed J E Health. 2011 Dec;17(10):814-37. doi: 10.1089/tmj.2011.0075. Epub 2011 Oct 4. Review. PubMed PMID: 21970573.
Copyright	© openEHR Foundation
Authors	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2008-07-27
Other Details Language	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2008-07-27
OtherDetails Language Independent	{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, references=Lamirel C, Bruce BB, Wright DW, Delaney KP, Newman NJ, Biousse V. Quality of nonmydriatic digital fundus photography obtained by nurse practitioners in the emergency department: the FOTO-ED study. Ophthalmology. 2012 Mar;119(3):617-24. doi: 10.1016/j.ophtha.2011.09.013. Epub 2012 Jan 3. PubMed PMID: 22218140; PubMed Central PMCID: PMC3294008. Grading diabetic retinopathy from stereoscopic color fundus photographs--an extension of the modified Airlie House classification. ETDRS report number 10. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. 1991 May;98(5 Suppl):786-806. PubMed PMID: 2062513. Li HK, Horton M, Bursell SE, Cavallerano J, Zimmer-Galler I, Tennant M, Abramoff M, Chaum E, Debuc DC, Leonard-Martin T, Winchester M; American Telemedicine Association Diabetic Retinopathy Telehealth Practice Recommendations Working Group., Lawrence MG, Bauman W, Gardner WK, Hildebran L, Federman J. Telehealth practice recommendations for diabetic retinopathy, second edition. Telemed J E Health. 2011 Dec;17(10):814-37. doi: 10.1089/tmj.2011.0075. Epub 2011 Oct 4. Review. PubMed PMID: 21970573., current_contact=Aitor Eguzkitza, Universidad Pública de Navarra - Complejo Hospitalario de Navarra, aitor.eguzkiza@unavarra.es, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=35074AFD3D2DD6088CF87CA1A24BD187, build_uid=6db14fdc-80d2-4a8e-9e26-61a1d2a9b1c4, ip_acknowledgements=This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org., revision=0.0.1-alpha}
Keywords
Lifecycle	in_development
UID	d8e13c17-6da2-40b7-b945-5f93df77daa4
Language used	en
Citeable Identifier	1013.1.208
Revision Number	0.0.1-alpha
All	Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Record of clinical findings on fundoscopy of eyes., archetypeConceptComment=null, otherContributors=Aitor Eguzkitza, Universidad Pública de Navarra - Complejo Hospitalario de Navarra, aitor.eguzkiza@unavarra.es Luis Serrano, Universidad Pública de Navarra (UPNA), lserrano@unavarra.es José Andonegui, Hospital de Navarra, jose.andonegui.navarro@cfnavarra.es Heather Leslie, Atomica Informatics, Australia, originalLanguage=en, translators= Portuguese (Brazil): Marco Borges, P2D, marco.borges@p2d.com.br Spanish (Spain): Aitor Eguzkitza, Universidad Pública de Navarra - Complejo Hospitalario de Navarra, aitor.eguzkiza@unavarra.es , subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={items=[], contacts=[], state=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/state[at0013]/items[at0140], code=at0140, itemType=ELEMENT, level=4, text=Confounding factors, description=Narrative description of factors, not recorded elsewhere, that may influence the clinical findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/state[at0013]/items[at0014], code=at0014, itemType=ELEMENT, level=4, text=Mydriatic used, description=True if mydriatic is used., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/state[at0013]/items[at0054], code=at0054, itemType=ELEMENT, level=4, text=Small pupil, description=True if during the acquisition, pupil diameter is smaller than normal (3,3mm)., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/state[at0013]/items[at0124], code=at0124, itemType=ELEMENT, level=4, text=Uncooperative patient, description=True if patient doesn't collaborate during the image acquisition., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null]], capabilities=[], relationships=[], context=[], description=[], ism_transition=[], identities=[], target=[], credentials=[], other_participations=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136], code=at0136, itemType=CLUSTER, level=4, text=Test Result, description=Details of the funduscopic examination test result for each eye., comment=null, uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, cardinalityFormal=1.., cardinalityText= (Cardinality: 1.., unordered), subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Eye examined, description=Identification of the eye which is being examined., comment=Matches to DICOM Laterality (0020,0060) attribute., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0137::Left eye [The left eye was examined.] [SNOMED-CT::362503005 \| Entire left eye] at0138::Right eye [The right eye was examined.] [SNOMED-CT::362502000 \| Entire right eye] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0008], code=at0008, itemType=ELEMENT, level=5, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination of the eye examined., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0053], code=at0053, itemType=ELEMENT, level=5, text=Red reflex, description=True if Red Reflex is present., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0091], code=at0091, itemType=ELEMENT, level=5, text=Optic disc description, description=Narrative description about the optic disc., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0090], code=at0090, itemType=ELEMENT, level=5, text=Macula description, description=Narrative description about the macula., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0092], code=at0092, itemType=ELEMENT, level=5, text=Retinal arteries description, description=Narrative description about the retinal arteries., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0093], code=at0093, itemType=ELEMENT, level=5, text=Retinal veins description, description=Narrative description about the retinal veins., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0094], code=at0094, itemType=ELEMENT, level=5, text=Retinal background description, description=Narrative description about the retinal background., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0098], code=at0098, itemType=ELEMENT, level=5, text=Vitreous description, description=Narrative description about the vitreous humour., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0143], code=at0143, itemType=ELEMENT, level=5, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings for the eye examined., comment=Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0142], code=at0142, itemType=SLOT, level=5, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* openEHR-EHR-CLUSTER.multimedia.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0139], code=at0139, itemType=SLOT, level=5, text=Additional findings, description=Additional structured details about the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* openEHR-EHR-CLUSTER.clinical_findings.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0141], code=at0141, itemType=SLOT, level=5, text=Examination not done, description=Details to explicitly record that this examination was not performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0126], code=at0126, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], content=[], source=[], events=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=2, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=null, extendedValues=null]], provider=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0029], code=at0029, itemType=ELEMENT, level=2, text=Method, description=Method chosen to perform the funduscopic examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0030::Direct [Study performed by direct ophthalmoscopy.] at0031::Indirect [Study of eye fundus by indirect ophthalmoscopy method.] at0131::Contact lens biomicroscopy [Eye fundus viewing through biomicroscopy lens in contact to patient's eye surface.] at0132::Non-contact lens biomicroscopy [Eye fundus viewing through biomicroscopy lens without contact to patient's eye surface.] at0129::Mydriatic retinography [Observation of retina through funduscopic images acquired by previous dilatation of patient's pupils.] at0130::Non-mydriatic retinography [Observation of retina through funduscopic images acquired without previous dilatation of patient's pupils.] at0135::Angiography [Observation of the eye fundus using a fluorescent dye inyected to emphasize the blood vessels in the eye retina.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0089], code=at0089, itemType=SLOT, level=2, text=Device details, description=Details of the device used to acquire eye fundus images., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* openEHR-EHR-CLUSTER.device.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0067], code=at0067, itemType=ELEMENT, level=2, text=Field angle, description=Describes the optical acceptance angle of the lens used during the test., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0068::30º [30º angle used for small pupil (SP) capture (for patients with pupil diameter <3.3mm).] at0069::45º [45º angle used to acquire eye fundus of normal pupils.] at0122::60º [60º angle used to acquire eye fundus in some DR screening studies.] at0070::100º [Wide angle acquisition.] at0071::200º [Ultra-wide angle acquisition.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0072], code=at0072, itemType=ELEMENT, level=2, text=Attempts, description=Number of attempts before obtaining the acquisition (doesn't compute if test is repeated by a specific recognized technical failure)., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=1; max: <=3 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0073], code=at0073, itemType=CLUSTER, level=2, text=(Subdivision of the retina), description=Subdivision of the retina identifying eye fundus image locations., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1.., cardinalityText= (Cardinality: 1.., unordered), subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Runtime name constraint: ac0001::Subdivision of retina [], extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0073]/items[at0074], code=at0074, itemType=ELEMENT, level=3, text=(ETRDS fields), description=Subdivision of the retina based on Diabetic Retinopathy Study fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0075::Study field 1 [] at0076::Study field 2 [] at0077::Study field 3 [] at0078::Study field 4 [] at0079::Study field 5 [] at0080::Study field 6 [] at0081::Study field 7 [] Runtime name constraint: ac0002::Diabetic Retinopathy Study field [], extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0073]/items[at0082], code=at0082, itemType=ELEMENT, level=3, text=Mosaic and peripherals, description=Division of the retina in quadrants + mosaic obtained from the combination of them., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0083::Mosaic [Mosaic obtained from combining every peripheral acquisitions and the center one.] at0084::Central [Image centered on the macula.] at0085::Nasal [Image centered on the optic nerve or papila.] at0086::Temporal [Image centered on the temporal quadrant of the retina.] at0087::Superior [Image centered on the superior half of the retina.] at0088::Inferior [Image centered on the inferior half of the retina.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0056], code=at0056, itemType=ELEMENT, level=2, text=Shadow artifact, description=True if shadow artifact is present on the border of the image., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0055], code=at0055, itemType=ELEMENT, level=2, text=Cataract artifact, description=True if cataract obstructs the visualization of eye fundus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0059], code=at0059, itemType=ELEMENT, level=2, text=Quality of visualisation, description=Levels quantifying the quality of each acquisition, based in the ease to visualize the structures on the eye fundus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: at0060::Quality inadequate for any diagnostic purpose [] 2: at0061::Unable to exclude all emergent findings [] 3: at0062::Only able to exclude emergent findings [] 4: at0063::Quality not ideal, but is possible to exclude subtle findings [] 5: at0064::Ideal quality [] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0058], code=at0058, itemType=ELEMENT, level=2, text=Visualisation description, description=Narrative description about visualisation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0123], code=at0123, itemType=ELEMENT, level=2, text=High refraction, description=True if the refraction of the eye exceeds the range from -12D to +15D., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0144], code=at0144, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* All not explicitly excluded archetypes, extendedValues=null]], details=[], activities=[]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0.., subCardinalityText=Minimum of 0 items (Cardinality: 0.., unordered), dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], state=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/state[at0013], code=at0013, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0.., subCardinalityText=Minimum of 0 items (Cardinality: 0.., unordered), dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0028], code=at0028, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0.., subCardinalityText=Minimum of 0 items (Cardinality: 0.., unordered), dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0029], code=at0029, itemType=ELEMENT, level=2, text=Method, description=Method chosen to perform the funduscopic examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0030::Direct [Study performed by direct ophthalmoscopy.] at0031::Indirect [Study of eye fundus by indirect ophthalmoscopy method.] at0131::Contact lens biomicroscopy [Eye fundus viewing through biomicroscopy lens in contact to patient's eye surface.] at0132::Non-contact lens biomicroscopy [Eye fundus viewing through biomicroscopy lens without contact to patient's eye surface.] at0129::Mydriatic retinography [Observation of retina through funduscopic images acquired by previous dilatation of patient's pupils.] at0130::Non-mydriatic retinography [Observation of retina through funduscopic images acquired without previous dilatation of patient's pupils.] at0135::Angiography [Observation of the eye fundus using a fluorescent dye inyected to emphasize the blood vessels in the eye retina.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0089], code=at0089, itemType=SLOT, level=2, text=Device details, description=Details of the device used to acquire eye fundus images., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* openEHR-EHR-CLUSTER.device.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0067], code=at0067, itemType=ELEMENT, level=2, text=Field angle, description=Describes the optical acceptance angle of the lens used during the test., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0068::30º [30º angle used for small pupil (SP) capture (for patients with pupil diameter <3.3mm).] at0069::45º [45º angle used to acquire eye fundus of normal pupils.] at0122::60º [60º angle used to acquire eye fundus in some DR screening studies.] at0070::100º [Wide angle acquisition.] at0071::200º [Ultra-wide angle acquisition.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0072], code=at0072, itemType=ELEMENT, level=2, text=Attempts, description=Number of attempts before obtaining the acquisition (doesn't compute if test is repeated by a specific recognized technical failure)., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=1; max: <=3 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0073], code=at0073, itemType=CLUSTER, level=2, text=(Subdivision of the retina), description=Subdivision of the retina identifying eye fundus image locations., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1.., cardinalityText= (Cardinality: 1.., unordered), subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Runtime name constraint: ac0001::Subdivision of retina [], extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0073]/items[at0074], code=at0074, itemType=ELEMENT, level=3, text=(ETRDS fields), description=Subdivision of the retina based on Diabetic Retinopathy Study fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0075::Study field 1 [] at0076::Study field 2 [] at0077::Study field 3 [] at0078::Study field 4 [] at0079::Study field 5 [] at0080::Study field 6 [] at0081::Study field 7 [] Runtime name constraint: ac0002::Diabetic Retinopathy Study field [], extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0073]/items[at0082], code=at0082, itemType=ELEMENT, level=3, text=Mosaic and peripherals, description=Division of the retina in quadrants + mosaic obtained from the combination of them., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0083::Mosaic [Mosaic obtained from combining every peripheral acquisitions and the center one.] at0084::Central [Image centered on the macula.] at0085::Nasal [Image centered on the optic nerve or papila.] at0086::Temporal [Image centered on the temporal quadrant of the retina.] at0087::Superior [Image centered on the superior half of the retina.] at0088::Inferior [Image centered on the inferior half of the retina.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0056], code=at0056, itemType=ELEMENT, level=2, text=Shadow artifact, description=True if shadow artifact is present on the border of the image., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0055], code=at0055, itemType=ELEMENT, level=2, text=Cataract artifact, description=True if cataract obstructs the visualization of eye fundus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0059], code=at0059, itemType=ELEMENT, level=2, text=Quality of visualisation, description=Levels quantifying the quality of each acquisition, based in the ease to visualize the structures on the eye fundus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: at0060::Quality inadequate for any diagnostic purpose [] 2: at0061::Unable to exclude all emergent findings [] 3: at0062::Only able to exclude emergent findings [] 4: at0063::Quality not ideal, but is possible to exclude subtle findings [] 5: at0064::Ideal quality [] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0058], code=at0058, itemType=ELEMENT, level=2, text=Visualisation description, description=Narrative description about visualisation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0123], code=at0123, itemType=ELEMENT, level=2, text=High refraction, description=True if the refraction of the eye exceeds the range from -12D to +15D., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0144], code=at0144, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]